On Call Basics
Why we are usually called
-Vertebrobasilar insufficiency à vertigo
-Weird neuro stuff (walking probs, Guillian Barre, headaches)
-Altered Mental Status
-BS police à call us for conversion d/o type stuff
-Usually strokes or concern for status epilepticus
-Random weird cases
On Call Basics 2
MOST IMPORTANT SLIDE:
¤Any change in neurological exam requires a patient to be seen immediately by you or your senior.
¤This is important for our in-patients, consult patients, or patients we have already been consulted on.
Approach to Neuro Dx
¤1st: Is this neurological? Can a non-neurological diagnosis explain this problem?
¤2nd: What is the time course?
¤3rd: Where does it localize? CNS or PNS or multi-focal?
Onset | FOCAL | DIFFUSE
Acute |Vascular |Toxic/Metabolic
Chronic |Neoplastic |Neuro-
Acute: seconds to hours
Subacute: days to weeks
Chronic: months to years
¤Any acute neurological deficit that occurs suddenly is a stroke until proven otherwise
¤Once stroke is ruled out, other considerations include seizure (post-ictal phenomenon i.e. Todd’s paralysis) or complicated migraines
Neuro Diagnosis Approach: Localization
Lower Motor Neuron signs:
¤Fasiculations (observable muscle quivering)Decreased Tone
Upper Motor Neuron Signs
¤Babinskis and primitive frontal release signs
¤Arm extensor pattern, Leg flexor pattern
Who, What, Where, When, Why, and How?
-Risk factors for stroke: HTN, HLD, DM, obese, old age, tobacco
-If young and have stroke: then think trauma (vertebral dissection), autoimmune disease, hypercoaguable state, or congenital heart disease
¤What to ask?
-Ask about blood pressure, if its low (then they may still have a stroke but need to consider hemodynamic deficit)
-Ask about last time normal (time when they didn’t have any neurological deficits)
-Ask about what deficiencies they are having (speech issues, weakness, numbness)
Stroke Basics 2
Where to be admitted?
¤If tPA, then NSICU
¤If TIA with complete resolution, then floor unless BP is crazy (then NSICU)
Where is their stroke (localizing basics)?
¤Cortical findings: gaze preference, seizure, expressive or receptive aphasia (not dysarthria), neglect of one side of their body, bilateral visual field deficits
¤Brainstem findings: crossed sensory findings (i.e. L face, R body), eye movement issues, asymmetric pupils, ataxia, vertigo, nausea (will be mild), or weakness in all 4 extremities
Stroke Basics 3
Post tPA pearls:
¤Keep systolic BP <180 (use drip if necessary)
¤No anti-platelet therapy or subq Heparin for 24h
¤Reorder brain imaging 24h post tPA administration
¤If change in neuro exam, take this very seriously (check BP and get stat head CT)
¤If nauseated, then go see (could be head bleed)
¤If hypotensive, then give IV fluids and go evaluate
Who has seizures?
¤Risk factors to ask: head injury with loss of consciousness, family hx of seizures, childhood history of seizures or febrile seizures, and hx of meningitis/encephalitis
¤Remember you need to have a cortical lesion to seize.
-Subcortical disease does not cause seizures
Seizure Basics 2
What kinds of seizures are there?
-Occur from a specific side (one side) of the brain
-Simple partial: these are auras only (completely normal cognitively)
-Complex partial: altered level of consciousness (but they don’t have to completely lose consciousness); may stare, make weird sounds, do repetitive motions
-In adults with no prior history, are usually from withdrawal of a substance or metabolic.
-Usually full body rhythmic jerking. Ask about incontinence and tongue biting
-Can evolve from a partial seizure which then generalizes to involve both hemispheres resulting in a loss of consciousness
-Remember withdrawal seizures are always generalized seizures.
Seizure Basics 3
What should I ask the patient or family?
¤Seizure risk factors
¤Are these events stereotyped (the same every time)?
-Do you they have a warning prior to their event?
-Focality, such as head turning or eye deviation each time?
¤How long do they last?
¤How are they afterwards? Confused, tired, body aches?
¤Tongue biting, urinary incontinence?
¤Are they taking their seizure medication?
¤Any recent infection? Any recent head trauma? Sleeping well or poorly? Stress level?
Seizure Basics 4
Where to examine if someone calls you concerned about status and the patient is too altered to talk to you?
¤Pinch them at all 4 extremities via nailbed pressure and also try sternal rub.
¤If no movement, then my concern for status epilepticus is higher à consider continuous EEG (if you can’t explain their altered level of consciousness another way).
-For intubated patients: ask them to take them off of sedation for at least 5-10 minutes prior to your arrival.
-“Asking a neurologist to perform a neuro exam with sedation on is like asking an ophthalmologist to look at someone’s eyes with them covered up” – Dr. Kanter
Seizure Basics 5
Why do people have seizures?
¤Previously mentioned seizure risk factors
¤Note, however in about 50% of cases a cause is never found
¤Pneumonic: AEIOU TIPS
A: alcohol, anoxia
E: endocrine, electrolytes, encephalitis, epilepsy
T: tumor, trauma, toxic
I: insulin (hypoglycemia)
P: psychiatric disease (pseudo-seizures)
S: stroke, sub-dural hematoma, sub-arrachnoid hemorrhage
Seizure Basics 6
How do I workup new onset seizures?
¤MRI brain w and w/out contrast
¤Routine EEG (remember a normal or abnormal EEG does not necessarily rule in or out seizures)
-EEG tells us whether the brain is primed to seize (epileptiform discharges are what are concerning on EEG, not slowing)
¤Labs: order renal, liver, urine drug screen, and seizure medication level (if on Dilantin or Tegretol)
Seizure Basics 7
How to treat seizures?
¤Acute: give them Ativan 2mg, if they seize again, then give another 2mg. Remember 4mg of Ativan in 5-10 minutes can be a recipe for intubation (get drowsy)
-If Ativan fails, then give a Fosphenytoin load (20 mg/kg IV x 1). Maintence Fosphenytoin is given 5mg/kg divided bid or tid.
Dilantin level management (7-11 rule)
-If <7, then increase TOTAL dose by 100mg
-If between 7-11, then increase TOTAL dose by 50mg
-If greater than 11, then increase TOTAL dose by 30mg
On Call Basics
Remember should you have any concerns, then call or find your senior.
¤Any change in neurological exam requires a patient to be seen immediately by you and/or your senior.